1. Steps in Nursing Process
    • Assessment
    • Diagnosis
    • Outcomes
    • Planning
    • Implementation
    • Evaluation
  2. HEADSSS Psychosocial Interview for adolescents:
    • H - ome
    • E - ducation and employment
    • A - ctivities (sports, peer relationships)
    • D - rugs, alcohol, tobacco use
    • S - ex (active, safe sex/contraception)
    • S - uicide risks, symptoms of depression
    • S - avagery (violence or abuse at home or in neighborhood.
  3. Assessing older Pts.
    Identify any physical deficits at the onset and make accommodations for them - hard of hearing
  4. The purpose of the psychiatric mental health nursing assessment is to:
    • Establish rapport
    • Obtain an understanding of the current problem or chief complaint
    • Review physical status and obtain baseline vital signs
    • Assess for risk factors affecting the safety of the patient or others
    • Perform a mental status examination
    • Assess psychosocial status
    • Identify mutual goals for treatment
    • Formulate a plan of care
  5. Neurological disorders that may mimic Depression but NOT Anxiety
    • Epilepsy (seizure disorder)
    • Multiple sclerosis
    • Parkinson's disease
  6. Infections that may mimic Depression or Anxiety
  7. Infections that may mimic Depression but NOT Anxiety
    • Mononucleosis
    • Hepatitis
    • Tertiary syphilis
    • Human immunodeficiency virus (HIV) infection
  8. Endocrine Disorder that may mimic Depression or Anxiety
    Hypothyroidism and hyperthyroidism
  9. Endocrine Disorders that may mimic Depression but not Anxiety
    • Cushing's syndrome
    • Addison's disease
    • Parathyroid disease
  10. Gastrointestinal Disorders that may mimic Depression
    • Liver cirrhosis
    • Pancreatitis
  11. Cardiovascular Disorders that may mimic Depression or Anxiety
    Congestive heart failure
  12. Cardiovascular Disorder that may mimic Depression but NOT Anxiety
  13. Respiratory Disorders that may mimic Depression alone
    Sleep Apnea
  14. Nutritional Disorders that may mimic Depression

    No Nutritional/Anxiety links
    • Thiamine deficiency
    • Protein deficiency
    • B12 deficiency
    • B6 deficiency
    • Folate deficiency
  15. Collagen vascular diseases that may mimic Depression
    • Lupus erythematosus
    • Rheumatoid arthritis
  16. Diseases that may mimic Depression
  17. Neurological disorders that may mimic Anxiety or Depression
    • Alzheimer's disease
    • Brain tumor
    • Stroke
    • Huntington's disease
  18. Infections that may mimic Anxiety
    • Encephalitis (also Depression)
    • Meningitis
    • Neurosyphilis
    • Septicemia
  19. Endocrine disorders that may mimic Anxiety but NOT Depression
    • Hypoparathyroidism
    • Hypoglycemia
    • Pheochromocytoma
    • Carcinoid
  20. Metabolic disorders that may mimic Anxiety

    No Metabolic/Depression links
    • Low calcium
    • Low potassium
    • Acute intermittent porphyria
    • Liver failure
  21. Cardiovascular disorders that may mimic Anxiety but NOT Depression
    • Angina
    • Pulmonary embolus
  22. Respiratory disorders that may mimic Anxiety alone
    • Pneumothorax
    • Acute asthma
    • Emphysema
  23. Drug effects that may mimic Anxiety or Psychosis
  24. Drug effects that may mimic Anxiety only
    • Sedatives (withdrawal)
    • Lead, mercury poisoning
  25. Medical Conditions that may mimic Psychosis
    • Temporal lobe epilepsy
    • Migraine headaches
    • Temporal arteritis
    • Occipital tumors
    • Narcolepsy
    • Encephalitis
    • Hypothyroidism
    • Addison's disease
    • HIV infection
  26. Drug effects that may mimic Psychosis only
    • Hallucinogens (e.g., LSD)
    • Phencyclidine
    • Alcohol withdrawal
    • Cocaine
    • Corticosteroids
  27. MSE stands for AAA and it is used to collect and organize BBB date about the patient.
    • A) Mental Status Examination
    • B) objective
  28. MSE Includes...
    • Appearance
    • • Grooming and dress
    • • Level of hygiene
    • • Pupil dilation or constriction
    • • Facial expression
    • • Height, weight, nutritional status
    • • Presence of body piercing or tattoos, scars, etc.
    • • Relationship between appearance and age

    • Behavior
    • • Excessive or reduced body movements
    • • Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of conscious-ness, balance and gait)
    • • Abnormal movements (e.g., tardive dyskinesia, tremors)
    • • Level of eye contact (keep cultural differences in mind)

    • Speech
    • • Rate: slow, rapid, normal
    • • Volume: loud, soft, normal
    • • Disturbances  (e.g.,   articulation  problems, slurring, stuttering, mumbling)• Cluttering (e.g., rapid, disorganized, tongue-tied speech)

    • Mood
    • Affect: flat, bland, animated, angry, withdrawn, appropriate to context
    • Mood: sad, labile, euphoric

    • Disorders of the Form of Thought
    • • Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality)
    • • Thought content (e.g., delusions, obsessions)

    • Perceptual Disturbances
    • • Hallucinations (e.g., auditory, visual)
    • Illusions

    • Cognition
    • • Orientation: time, place, person
    • • Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)
    • • Memory: remote, recent, immediate
    • • Fund of knowledge
    • • Attention: performance on serial sevens, digit span tests
    • • Abstraction: performance on tests involving similarities, proverbs
    • Insight - what do they know about their own disease
    • • Judgment

    • Ideas of Harming Self or Others
    • • Suicidal or homicidal thoughts:
    • • Presence of a plan
    • • Means to carry out the plan
    • • Opportunity to carry out the plan
  29. Psychosocial Assessment includes:
    • A Previous hospitalizations
    • B. Educational background
    • C. Occupational background
    • D. Social patterns - family/friends
    • E. Sexual patterns
    • F. Interests & Abilities
    • G. Substance use & abuse
    • H. Coping abilities
    • I. Spiritual assessment
  30. Components of a Nursing Diagnosis
    • Problem
    • Etiology related to
    • Supporting data as evidenced by
  31. Outcomes (third step in nursing process after Diagnosis) have these three criteria:
    • Attainable
    • Measurable
    • Time estimate for attainment
  32. Planning, the 4th step of the nursing process, identifies Interventions that are:
    • Safe
    • Compatible & appropriate
    • Realistic & Individualized
    • Evidence based
  33. Spirituality has three dimensions: AAA. BBB and CCC. The AAA component includes beliefs, such as believing in the love of a spouse. The CCC component deals with daily behaviors and life choices, such as finding the time to pray or being happy with choices one makes in life, whether others support those choices or not. The BBB component deals with love, compassion, altruism, and forgiveness.
    • A) cognitive
    • B) experiential
    • C) behavioral
  34. In psychiatric nursing, assessment of a "client" refers exclusively to

    C. an individual, family, group, or community.

    Standards of practice for psychiatric nursing indicate that the client can be an individual, a family, a group, or a community. Text page: 138
  35. High levels of anxiety and maladaptive behavior are 

    D. in all areas in the health care setting.

    Anxiety occurs whenever individuals are faced with unfamiliar circumstances or other threats to the self. The health care setting presents many possible threats to the self, such as illness, disability, surgery, and pain. Text page: 140
  36. Which activity is not considered a purpose of initial psychiatric assessment? 

    B. Evaluate results of intervention

    At an initial assessment, no interventions would have taken place; hence evaluation is not a purpose of the initial contact. Text pages: 140, 141
  37. The nurse best ensures appropriate client care when choosing an intervention from a Nursing Interventions Classification that match the: 

    B. the defining data and nursing diagnosis

    When choosing a nursing intervention from the Nursing Interventions Classification or other source, the nurse uses ones that fit the nursing diagnosis (e.g., risk for suicide) and interventions that match the defining data. Text pages: 147, 148
  38. What three structural components comprise a nursing diagnosis? 

    A. Problem, etiology, supporting data
  39. A beginning nurse writing outcome criteria might refer to the: 

    C. Nursing Outcomes Classification (NOC).
  40. When planning care the nurse may eliminate which of the following as an essential principle? Which criterion is not essential for the nurse to observe when planning nursing interventions designed to meet a specific goal? The intervention will be 

    A. Interventions must be supported by the Nursing Outcomes Classification.

    NOC does not distinguish between short- and long-term outcomes. However, the clinical chapters of the text distinguish among the outcomes to demonstrate that the achievement of some outcomes is possible in the short term, whereas others will require more time with the client. Text page: 149
  41. Interviewer anxiety during an assessment interview is most likely to stem from 

    B. the client's perception of the interviewer's ability to help the client.

    A. the client's perception of the interviewer's ability to help the client.
  42. A factor that will interfere most with obtaining data in an initial assessment interview of an older adult is 

    C. client's physical and cognitive deficiencies.
  43. A nurse is interviewing a new client who is angry and highly suspicious. When the nurse asks about a client's sexual orientation, the client becomes highly distressed and threatens to walk out of the interview. The nurse should say 

    A. "I can see that this topic makes you uncomfortable. We can defer discussion of it today."

    A cardinal rule of interviewing is "Don't probe sensitive areas." Clients are allowed to take the lead. Text page: 140
  44. A nurse is about to interview a client whose glasses and hearing aid were placed in safe keeping when she was admitted. Before beginning the interview, the nursing intervention that will best facilitate data collection is to 

    D. assist the client in putting on glasses and hearing aid.

    A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. Text page: 140
Card Set
The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing